Congress passed Public Law 101-590, the Trauma Care Systems Planning and Development Act, in 1990. The value of implementing trauma systems through statewide planning has been recognized and has already demonstrated that these organized regional systems result in dramatic improvements in patient outcomes. These systems are designed so that patients with catastrophic injuries will have the quickest possible access to an established trauma center or a hospital that has the capabilities to provide comprehensive emergency medical care. These systems ensure that the severely injured patient can be rapidly cared for in the facility that is most appropriately prepared to treat the severity of injury.
Unfortunately, in some situations, managed care systems or insurers have interfered with and defeated the purpose of trauma system networks because:
(A) The managed care system or insurer may not authorize treatment for a severely injured patient unless there is prior authorization. On many nights and weekends, prompt prior authorization is almost impossible to obtain. Trauma is by definition an emergency condition, and treatment cannot wait for such delays.
(B) The managed care system or insurer may deny coverage unless the patient is transferred either to a hospital with which there is an existing contract or to a hospital where specific doctors who are already contracted to the health care entity have privileges and practice medicine. This forced triage may not be appropriate for the severity of the patient's injury and, therefore, may not be in the injured patient's best medical interests.
(C) In many instances in which care has been provided at a trauma center, reimbursement from the managed care system or insurer has been denied or severely limited.
Trauma systems have been designed to provide the most rapid, coordinated medical services to injured patients. The American College of Surgeons believes that managed care plans and insurers should be required to allow their patients to be treated in trauma centers or emergency facilities when true medical emergencies arise. Delaying or denying approval in such circumstances, or requiring transfer to another facility as a condition of payment, may seriously compromise the effective medical treatment of a severely injured patient.
Agreement upon the following principles should ensure that any patient brought to a trauma center will receive the best possible medical care:
- No impediment to prompt acute trauma care as determined by the regional trauma system should be permitted.
- Approval for treatment should be automatic when admissions or transfers are deemed necessary by the physician or surgeon at the trauma facility.
- Prompt reimbursement for all trauma care at trauma centers that have been verified by the American College of Surgeons and/or verified by the state should be the norm.
- Managed care systems and trauma centers should establish agreements to ensure that transfer does not interrupt continuity of vital medical care for injured patients and result in avoidable complications.
- There should be no barriers to the exchange of data allowing for procedures to monitor the quality of performance and verification of the outcome of the care of trauma patients.
- A mechanism for the rapid and appropriate resolution of conflicts should be in place.
Trauma centers and managed care agencies should coordinate their efforts to obtain long-term outcome and cost data in order to promote optimal patient management. All decisions to transfer a patient should require a physician-to-physician request and should be based on the patient's condition and the appropriateness of the receiving facility's resources relative to the patient's needs. The final decision to transfer the patient should remain with the trauma surgeon, who, as attending physician, has the best information regarding the patient's injuries, condition, and needs.
These types of patient care guarantees should be incorporated in licensing requirements for managed care health systems and insurers in all states.
Reprinted from Bulletin of the American College of Surgeons
Vol. 80, No. 1, Pages 86-87, January 1995
